It took intensive lobbying by President Bush and House Republican leaders, combined with the longest floor vote on record, to pull off House passage early Saturday morning of the most significant Medicare overhaul in the program's 38-year history.

The House vote began at 3 a.m., and by 5 a.m. it appeared the Medicare legislation would be rejected 216-218. But the Republican whip operation, aided by telephone calls to lawmakers from Bush and work on the House floor by Health and Human Services Secretary Tommy G. Thompson, then persuaded six lawmakers to switch their votes.

Shortly before 6 a.m. — 2 hours and 51 minutes after the voting began — the House adopted the conference report on the legislation (HR 1 — H Rept 108-391) by a final tally of 220-215.

Speaker J. Dennis Hastert, R-Ill., hailed the outcome as the "probably one of the most important votes in the last two generations. . . .This is a very important bill and you know we had to get it done."

But Democrats accused Republicans of strong-arming the bill to passage.

John D. Dingell, D-Mich., whose father helped pen early versions of what became the original 1965 Medicare law, called the vote "one of the most arrogant exercises of abuse of power I've seen in my career."

"Tonight, for a historic three hours, the seniors of America won," said Minority Whip Steny B. Hoyer, D-Md., referring to the time when the bill appeared to be failing. "The majority of members concluded it was not a good bill."

The President on the Phone
Bush, just back from a trip to England, spent Friday night lobbying for House votes. One convert was C. L. "Butch" Otter, R-Idaho, who switched his vote and supported the conference report after receiving a call from the president and minutes before the vote ended. "He asked me what my problem was. My problem was we didn't pay for it," Otter said.

The leadership lobbying offensive involved more than appeals to party unity. Lawmakers also debated the merits of the legislation, which would provide seniors with a limited prescription drug benefit while making other significant changes in the program.

Otter and six other Republicans who initially voted against the bill huddled privately, first near the rear of the House chamber and then in a private room off the floor. The leadership sent in Charles W. "Chip" Pickering Jr., R-Miss., an assistant majority whip, to offer a scenario of what could happen next if the House rejected the conference report. Pickering, a former aide to Sen. Trent Lott, R-Miss., said House Democrats would likely be able to gather enough signatures on a discharge petition to force a House vote on an earlier Senate-passed version of the Medicare bill.

"I've seen those discharge petitions move pretty rapidly when they see that deals are being cut," Otter said. "If we lost this package, if we lost this bill, we weren't going to like what we'd end up with."

Cal Dooley, D-Calif., who initially voted against the conference report, said he switched to "yes" after he saw that Republicans had secured 206 votes for the legislation on their side of aisle. Dooley said he thought the legislation would help low-income seniors in his district, but wanted to see the Republican majority commit its votes.

GOP leaders said they put the Medicare package on the floor Friday evening without certainty that it would be adopted. "When you have a slim majority, that's what you have to do sometimes," said House GOP Conference Chairman Deborah Pryce, R-Ohio.

"It's nicer if you can win easy, but this was an absolute have-to," Pryce said. "I was the one who advocated the Senate go first. . . . Looking back, maybe they should have."

Pryce said she does not expect Senate Democratic opponents of the legislation to attempt to block the conference report with a filibuster in response to the contentious debate and close vote in the House. "I think the votes are pretty much lined up over there," she said.

Just before 6 a.m., Thompson strode down the House chamber's center aisle, stopping to shake the hands of lawmakers who had responded to the administration's pleas. Earlier in the night, the Cabinet member worked the floor vigorously, scavenging for votes.

"There was a lot of discussion and a lot of persuasion," Thompson said as he left the chamber.

Not all of Thompson's efforts were successful. He and Hastert huddled with Michigan Republican Nick Smith, but could not win his vote.

In the end, 25 Republicans bucked their leadership and voted against the bill, while 16 Democrats voted for the conference report.

Republicans who switched their votes from "no" to "yes" included Otter, Trent Franks of Arizona and Ernest Istook of Oklahoma.

Democrats who switched from "no" to "yes" were Dooley and Georgians Jim Marshall and David Scott.

Republicans Jo Ann Emerson of Missouri and Gil Gutknecht of Minnesota, who opposed the bill's restrictions on importing less costly prescription drugs, were among the first to cast their votes against the bill. Both then promptly left the chamber to avoid a rerun of events during the June 27 House vote on the Medicare bill. Then, Emerson changed her vote to "yes" after the leadership promised her a separate vote on the importation provisions.

Emerson returned later to watch the vote, but stood at the back of the Democratic side of the chamber.

David Wu, D-Ore., cast the last vote. Assured that his vote would not determine the outcome, Wu voted "yes" just before 6 a.m.

The Senate is expected to take up the Medicare conference report on Monday.

Conservatives Reluctant
Bush and his congressional allies made overhauling the Great Society program their top domestic policy priority this year. But the victory came only after House GOP leaders succeeded in persuading enough of the chamber's conservatives to support the overhaul, despite concerns about the way it would dramatically increase mandatory spending.

The bill would create an outpatient prescription drug benefit for Medicare's more than 40 million beneficiaries. It also would expand the role that private health plans play in delivering benefits. The Congressional Budget Office (CBO) estimated the legislation would cost $394.3 billion over 10 years, just below the $400 billion allowed in the fiscal 2004 budget resolution (H Con Res 95).

All day Friday, the leadership and the White House worked hard to sway wavering lawmakers. But demonstrating the uncertainty of the outcome, GOP leaders earlier had fudged on whether they would take the conference report to the floor Friday evening. Asked that question as he emerged from an afternoon meeting with Senate Majority Leader Bill Frist, R-Tenn., Hastert replied: "I think so, but it's very tenuous."

House Minority Leader Nancy Pelosi, D-Calif., told a crowded Democratic Caucus meeting on Friday morning that if Republicans prevailed on the measure because of Democratic votes it would be "disastrous" for the party, one attendee reported.

"She talked about the bill in terms of unity — not threats," a top Pelosi aide said.

But some Democrats, including Bob Filner of California, wanted consequences attached to defections. "We want to see some punishment," he said.

Top aides to Pelosi said there were no firm plans to punish Democrats who voted for the measure. "Their bigger problem is interpersonal with other members," one aide said. "Members are looking at this vote."

Republican conservatives were under pressure from individuals and groups on the right to oppose the bill. Former House Majority Leader Dick Armey, R-Texas, opined against the measure in the Wall Street Journal on Friday morning, joining the paper's own editorialists.

Republican and Democratic conferees who helped draft the final version of the bill said it would not only add drug coverage to Medicare but also would cover more preventive care and create new policies that would help sustain the program financially for future generations.

Among its provisions, the bill would give a drug discount card to help seniors save money on their prescriptions before the full benefit would begin in 2006. Many low-income beneficiaries would receive financial help meeting monthly premiums and yearly deductibles and the government would guarantee drug coverage in any region of the country if private plans did not do so. Hospitals, physicians and other rural lawmakers would receive an additional $25 billion in payments over the next decade.

Beneficiaries new to the program would receive a baseline physical and those with chronic conditions could participate in disease management programs.

Starting in 2010, the traditional fee-for-service Medicare program would have to compete directly with private insurers in six metropolitan statistical areas for six years.